Incidence and prevalence of immune thrombocytopenia under the copayment waiver policy for pediatric patients in Korea: Data from the National Health Claims Database.

The purpose of this study was to investigate the epidemiology of immune thrombocytopenia (ITP) under the copayment waiver policy for pediatric patients in Korea. The data were collected from the National Health Insurance Claims Database of Korea. ITP was identified based on the diagnostic code D69.38 from the Korean Standard Classification of Diseases. Patients between one and 18 years old, who had at least one health insurance claim for ITP as a final diagnosis, from 1 January 2016, to 31 December 2017, were analyzed. Prevalent cases were defined as patients who used, at least one time, any medical services coded as D69.38. Incident cases were defined as patients who did not use D69.38 coded medical services during the prior year and were newly registered in 2017. The prevalence and incidence of ITP were 24.53 and 13.39 per 100,000 persons. The peak rates were observed in 1-year-old patients. The gender-specific prevalence of ITP was significantly higher in one-year-old males than females. According to the change-point analysis, we found that the prevalence and incidence diminished rapidly at the ages of four and three, respectively. This Korean population-based epidemiological study of ITP provided meaningful insights into the current epidemiology of ITP and demonstrated the implications of interpreting epidemiologic studies to reflect age categorizing and health care system characteristics.

Peritoneal dialysis: Status report in South and South East Asia.

BACKGROUND: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region. METHODS: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups. RESULTS: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization. CONCLUSION: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

How time horizons of autocrats impact health expenditure: a mixed methods research.

BACKGROUND: A country's spending on healthcare significantly improves its population health status. No comparative study has examined how the threat perceived by leaders influences health expenditure and cross-national analyses of authoritarian regimes. The objectives of this study are to examine how time horizons of autocrats influence health expenditure. METHODS: We designed a mixed methods research approach. First, the study used panel data from 1995 to 2010 covering 95 countries (n = 1208) and applied fixed effects regression models. As a proxy for time horizons, the study generated the predicted survival time for each regime-year using parametric survival analysis and the predictors to model regime failure. Second, we chose Chad, Rwanda and Ivory Coast to apply synthetic control methods for comparative case studies. Armed conflict had significant effects on regime duration and was used for an intervention. We constructed a synthetic version of each country, combining counties that did not or did experience armed conflict to resemble the values of health expenditure predictors for the actual country prior to the intervention. RESULTS: We found that an increase in the natural log form of survival time by 1 resulted in a 1.14 percentage point increase in health expenditure (% of GDP) (1.14, 95% CI = 0.60-1.69). Furthermore, we found that the difference in health expenditure between the actual Chad and its synthetic version starts to grow following the civil war in 2004 (in 2004, actual: 5.72%, synthetic: 5.91%; in 2005, actual: 3.91%, synthetic: 6.74%). Similarly, a large health expenditure gap between the actual Rwanda and its synthetic control resulted after the peace deal was signed in 2002 (in 2002, actual: 4.18%, synthetic: 4.77%; in 2003, actual: 6.34%, synthetic: 5.03%). In Ivory Coast, the two series diverge substantially during the civil war from 1999 to 2005 (in 1998, actual: 7.30%, synthetic: 7.11%; in 2002, actual: 4.47%, synthetic: 7.43%; in 2007, actual: 6.35%, synthetic: 6.50%). CONCLUSIONS: The findings suggest that health expenditure decreases as regime time horizons shrink, and reducing armed conflict is a way to promote regime stability.

Association of State Certificate of Need Regulation With Procedural Volume, Market Share, and Outcomes Among Medicare Beneficiaries.

Importance: Certificate of need laws provide state-level regulation of health system expenditure. These laws are intended to limit spending and control hospital expansion in order to prevent excess capacity and improve quality of care. Several states have recently introduced legislation to modify or repeal these regulations, as encouraged by executive order 13813, issued in October 2017 by the Trump administration. Objective: To evaluate the difference in markers of hospital activity and quality by state certificate of need status. These markers include hospital procedural volume, hospital market share, county-level procedures per 10 000 persons, and patient-level postoperative outcomes. Design, Setting, and Participants: A cross-sectional study involving Medicare beneficiaries aged 65 years or older who underwent 1 of the following 10 procedures from January 1, 2016, through November 30, 2018: total knee or hip arthroplasty, coronary artery bypass grafting, colectomy, ventral hernia repair, lower extremity vascular bypass, lung resection, pancreatic resection, cystectomy, or esophagectomy. Exposures: State certificate of need regulation status as determined by data from the National Conference of State Legislatures. Main Outcomes and Measures: Outcomes of interest included hospital procedural volume; hospital market share (range, 0-1; reflecting 0%-100% of market share); county-level procedures per 10 000 persons; and patient-level postoperative 30-day mortality, surgical site infection, and readmission. Results: A total of 1 545 952 patients (58.0% women; median age 72 years; interquartile range, 68-77 years) at 3631 hospitals underwent 1 of the 10 operations. Of these patients, 468 236 (30.3%) underwent procedures in the 15 states without certificate of need regulations and 1 077 716 (69.7%) in the 35 states with certificate of need regulations. The total number of procedures ranged between 729 855 total knee arthroplasties (47.21%) and 4558 esophagectomies (0.29%). When comparing states without vs with certificate of need regulations, there were no significant differences in overall hospital procedural volume (median hospital procedure volume, 241 vs 272 operations per hospital for 3 years; absolute difference, 31; 95% CI, -27.64 to 89.64; P = .30). There were no statistically significant differences between states without vs with certificate of need regulations for median hospital market share (median, 28% vs 52%; absolute difference, 24%; 95% CI, -5% to 55%; P = .11); procedure rates per 10 000 Medicare-eligible population (median, 239.23 vs 205.41 operations per Medicare-eligible population in 3 years; absolute difference, 33.82; 95% CI, -84.08 to 16.43; P = .19); or 30-day mortality (1.17% vs 1.33%, odds ratio [OR], 1.04; 95% CI, 0.93 to 1.16; P = .52), surgical site infection (1.24% vs 1.25%; OR, 0.93; 95% CI, 0.83 to 1.04; P = .21), or readmission rate (9.69% vs 8.40%; OR, 0.80; 95% CI, 0.57 to 1.12; P = .19). Conclusions and Relevance: Among Medicare beneficiaries who underwent a range of surgical procedures from 2016 through 2018, there were no significant differences in markers of hospital volume or quality between states without vs with certificate of need laws. Policy makers should consider reevaluating whether the current approach to certificate of need regulation is achieving the intended objectives and whether those objectives should be updated.

Conditional Financing of Drugs in the Netherlands: Past, Present, and Future-Results From Stakeholder Interviews.

BACKGROUND: Conditional financing (CF) of hospital drugs was implemented in the Netherlands as a form of managed entry agreements between 2006 and 2012. CF was a 4-year process comprising 3 stages: initial health technology assessment of the drug (T = 0), conduct of outcomes research studies, and reassessment of the drug (T = 4). OBJECTIVES: To analyze stakeholder experiences in implementing CF in practice. METHODS: Public and private stakeholders were approached for participation in stakeholder interviews through standardized email invitations. An interview guide was developed to guide discussions that covered the following topics: perceived aims of CF, functioning of CF, impact of CF, and conclusions and future perspectives. Extensive summaries were generated for each interview and subsequently used for directed content analysis. RESULTS: Thirty stakeholders were interviewed. Differences emerged among the stakeholders on the perceived aims of CF. Conversely, there was some agreement among stakeholders on the shortcomings in the functioning of CF, the positive impact of CF on the Dutch healthcare setting, and improvement points for CF. CONCLUSIONS: Despite stakeholders' belief that CF either did not meet its aims or only partially did so, there was agreement on the need for new policy to address the same aims of CF in the future. Nevertheless, stakeholders diverged on whether CF should be improved on the basis of learnings identified and reintroduced into practice or replaced with new policy schemes.

Affordable and equitable access to subsidised outpatient medicines? Analysis of co-payments under the Additional Drug Package in Kyrgyzstan.

BACKGROUND: Out-of-pocket (OOP) payments can constitute a major barrier for affordable and equitable access to essential medicines. Household surveys in Kyrgyzstan pointed to a perceived growth in OOP payments for outpatient medicines, including those covered by the benefits package scheme (the Additional Drug Package, ADP). The study aimed to explore the extent of co-payments for ADP-listed medicines and to explain the reasons for developments. METHODS: A descriptive statistical analysis was performed on prices and volumes of prescribed ADP-listed medicines dispensed in pharmacies during 2013-2015 (1,041,777 prescriptions claimed, data provided by the Mandatory Health Insurance Fund). Additionally, data on the value and volume of imported medicines in 2013-2015 (obtained from the National Medicines Regulatory Agency) were analysed. RESULTS: In 2013-2015, co-payments for medicines dispensed under the ADP grew, on average, by 22.8%. Co-payments for ADP-listed medicines amounted to around 50% of a reimbursed baseline price, but as pharmacy retail prices were not regulated, co-payments tended to be higher in practice. The increase in co-payments coincided with a reduction in the number of prescriptions dispensed (by 14%) and an increase in average amounts reimbursed per prescription in nearly all therapeutic groups (by 22%) in the study period. While the decrease in prescriptions suggests possible underuse, as patients might forego filling prescriptions due to financial restraints, the growth in average amounts reimbursed could be an indication of inefficiencies in public funding. Variation between the regions suggests regional inequity. Devaluation of the national currency was observed, and the value of imported medicines increased by nearly 20%, whereas volumes of imports remained at around the same level in 2013-2015. Thus, patients and public procurers had to pay more for the same amount of medicines. CONCLUSIONS: The findings suggest an increase in pharmacy retail prices as the major driver for higher co-payments. The national currency devaluation contributed to the price increases, and the absence of medicine price regulation aggravated the effects of the depreciation. It is recommended that Kyrgyzstan should introduce medicine price regulation and exemptions for low-income people from co-payments to ensure a more affordable and equitable access to medicines.

Japan: achieving UHC by regulating payment.

The triple goals of Universal Health Coverage (UHC) are to cover the whole population, to reduce patients' costs, and to expand coverage to all effective services, equitably available to all. This paper analyses the experience of Japan in achieving these goals, focusing on the central role played by the payment system. The payment system, or fee schedule, sets the price of services and pharmaceuticals, as well as the conditions that providers must comply with in order to receive payment. The fee schedule was first introduced following the enactment of social health insurance (SHI) in 1922. Initially, the SHI program covered only manual workers, who comprised a mere 3% of the population. However, the fee schedule of the largest SHI plan was subsequently adopted by all other SHI plans. From 1958, there has been only one fee schedule. Population coverage was achieved in 1961 by mandating all residing in Japan to enroll in SHI, thereby making everyone entitled to all the services and pharmaceuticals listed in the fee schedule. Next, co-insurance was capped to an affordable level by the introduction of catastrophic coverage in 1973. Lastly, extra billing and balance billing were explicitly restricted in 1984. The key to achieving and sustaining UHC goals in Japan lies in being able to contain costs and reallocate resources by revising the fee schedule.

"Our fear is finished," but nothing changes: efforts of marginalized women to foment state accountability for maternal health care in a context of low state capacity.

BACKGROUND: Women in India are often asked to make informal payments for maternal health care services that the government has mandated to be free. This paper is a descriptive case study of a social accountability project undertaken by SAHAYOG, a nongovernmental organization in Uttar Pradesh, India. SAHAYOG worked with community-based organizations and a grassroots forum comprised of low caste, Muslim, and tribal women to decrease the prevalence of health provider demands that women and their families make informal payments. METHODS: The study entailed document review; interviews and focus group discussions with program implementers, governmental stakeholders, and community activists; and participant observation in health facilities. RESULTS: The study found that SAHAYOG adapted their strategy over time to engender greater empowerment and satisfaction among program participants, as well as greater impact on the health system. Participants gained knowledge resources and agency; they learned about their entitlements, had access to mechanisms for complaints, and, despite risk of retaliation, many felt capable of demanding their rights in a variety of fora. However, only program participants seemed successfully able to avoid making informal payments to the health sector; health providers still demanded that other women make payments. Several features of the micro and macro context shaped the trajectory of SAHAYOG's efforts, including deeply rooted caste dynamics, low provider commitment to ending informal payments, the embeddedness of informal payments, human resources scarcity, and the overlapping private interests of pharmaceutical companies and providers. CONCLUSION: Though changes were manifest in certain fora, providers have not necessarily embraced the notion of low caste, tribal, or Muslim women as citizens with entitlements, especially in the context of free government services for childbirth. Grassroots advocates, CBOs, and SAHAYOG assumed a supremely difficult task. Project strategy changes may have made the task somewhat less difficult, but given the population making the rights claims and the rights they were claiming, widespread changes in demands for informal payments may require a much larger and stronger coalition.

Breaking bread: examining the impact of policy changes in access to state-funded provisions of gluten-free foods in England.

BACKGROUND: Coeliac disease affects approximately 1% of the population and is increasingly diagnosed in the United Kingdom. A nationwide consultation in England has recommend that state-funded provisions for gluten-free (GF) food should be restricted to bread and mixes but not banned, yet financial strain has prompted regions of England to begin partially or fully ceasing access to these provisions. The impact of these policy changes on different stakeholders remains unclear. METHODS: Prescription data were collected for general practice services across England (n = 7176) to explore changes in National Health Service (NHS) expenditure on GF foods over time (2012-2017). The effects of sex, age, deprivation and rurality on GF product expenditure were estimated using a multi-level gamma regression model. Spending rate within NHS regions that had introduced a 'complete ban' or a 'complete ban with age-related exceptions' was compared to spending in the same time periods amongst NHS regions which continued to fund prescriptions for GF products. RESULTS: Annual expenditure on GF products in 2012 (before bans were introduced in any area) was £25.1 million. Higher levels of GF product expenditure were found in general practices in areas with lower levels of deprivation, higher levels of rurality and higher proportions of patients aged under 18 and over 75. Expenditure on GF food within localities that introduced a 'complete ban' or a 'complete ban with age-related exceptions' were reduced by approximately 80% within the 3 months following policy changes. If all regions had introduced a 'complete ban' policy in 2014, the NHS in England would have made an annual cost-saving of £21.1 million (equivalent to 0.24% of the total primary care medicines expenditure), assuming no negative sequelae. CONCLUSIONS: The introduction of more restrictive GF prescribing policies has been associated with 'quick wins' for NHS regions under extreme financial pressure. However, these initial savings will be largely negated if GF product policies revert to recently published national recommendations. Better evidence of the long-term impact of restricting GF prescribing on patient health, expenses and use of NHS services is needed to inform policy.

The impact of cost sharing on women's use of annual examinations and effective contraception.

BACKGROUND: We sought to describe the relationship between the elimination of out-of-pocket costs and women's use of preventive care office visits and long-acting reversible contraception after accounting for baseline levels of cost sharing. OBJECTIVES: The objective of this analysis was to describe the relationship between the elimination of out-of-pocket costs and utilization of preventive care visits and long-acting reversible contraception insertion while taking baseline cost sharing levels under consideration. STUDY DESIGN: In 2017, we used administrative health plan data to examine changes in out-of-pocket costs and service utilization among 2,172,065 women enrolled in 15,118 employer-based health plans between 2008 and 2015. We used generalized estimating equations to examine utilization patterns. RESULTS: Women in this sample generally had low costs at baseline ($24 and $29 for preventive care visits and long-acting reversible contraception insertion, respectively). The elimination of baseline out-of-pocket costs were related to changes in the utilization of both services but more consistently for contraceptive device placement. Women whose low/moderate out-of-pocket costs were eliminated were more likely to use a preventive care office visit than women with persistent low/moderate costs (odds ratio, 1.05; 95% confidence interval, 1.04-1.05), but women with high out-of-pocket costs had lower utilization rates, even after their costs were eliminated. In contrast, the odds of having a contraceptive device placed was higher among all groups of women when out-of-pocket costs were zero, as compared with women with low/moderate costs. For instance, when compared with women with low/moderate costs, women were less likely to have a contraceptive device inserted (odds ratio, 0.92; 95% confidence interval, 0.86-0.97) when they had high costs but more likely after their costs were eliminated (odds ratio, 1.15; 95% confidence interval, 1.09-1.20). CONCLUSION: Out-of-pocket costs were low prior to the Affordable Care Act. Eliminating costs was associated with increases in preventive service use among those with high levels of cost, but effect sizes were low, suggesting that cost is only 1 barrier. Failing to recognize that cost sharing was already low could cause us to falsely conclude that the elimination of cost sharing was ineffective.

Fiscal rules, powerful levers for controlling the health budget? Evidence from 32 OECD countries.

BACKGROUND: Publicly funded healthcare forms an intricate part of government spending in most Organisation for Economic Co-operation and Development (OECD) countries, because of its reliance on entitlements and dedicated revenue streams. The impact of budgetary rules and procedures on publicly funded health care might thus be different from other spending categories. In this study we focus on the potential of fiscal rules to contain these costs and their design features. METHODS: We assess the relationship between fiscal rules and the level of public health care expenditure of 32 (OECD) countries between 1985 and 2014. Our dataset consists of health care expenditure data of the OECD and data on fiscal rules of the International Monetary Fund (IMF) for that same period. Through a multivariate regression analysis, we estimate the association between fiscal rules and its subcategories and inflation adjusted public health care expenditure. We control for population, Gross Domestic Product (GDP), debt and whether countries received an IMF bailout for the specific period. In all our regressions we include country and year fixed effects. RESULTS: The presence of a fiscal rule on average is associated with a 3 % reduction of public health care expenditure. Supranational balanced budget rules are associated with some 8 % lower expenditure. Health service provision-oriented countries with more passive purchasing structures seem less capable of containing costs through fiscal rules. Fiscal rules demonstrate lagged effectiveness; the potential for expenditure reduction increases after one and two years of fiscal rule implementation. Finally, we find evidence that fiscal frameworks that incorporate multi-year expenditure ceilings show additional potential for cost control. CONCLUSIONS: Our study shows that there seems a clear relationship between the potential of fiscal rules and budgeting health expenses. Using fiscal rules to contain the level of health care expenditure can thus be a necessary precondition for successful strategies for cost control.

Closing the Medicare Doughnut Hole: Changes in Prescription Drug Utilization and Out-of-Pocket Spending Among Medicare Beneficiaries With Part D Coverage After the Affordable Care Act.

BACKGROUND: The Affordable Care Act (ACA) include provisions that reduce beneficiaries' cost sharing and eventually closes the coverage gap-known as the "doughnut hole"-that was originally part of Medicare prescription drug coverage implemented in 2006. OBJECTIVES: This study examines changes in overall prescription drug utilization and out-of-pocket spending as well as by manufacturer type (brand vs. generic), through 2013 as a result of the doughnut hole provisions of the ACA. MATERIALS AND METHODS: This analysis is based on data from Medical Expenditure Panel Survey and the sample for this analysis includes all individuals 55 years of age and older. A difference-in-differences methodology was adopted to measure changes in drug utilization and out-of-pocket spending among both the treatment group and the comparison group after the ACA. RESULTS: The findings from this study suggest that overall out-of-pocket spending significantly decreased after closing the coverage gap, mainly because of a significant reduction in out-of-pocket spending on brand-name drugs. Conversely, the results show that generic drug utilization increased after closing the coverage gap. As expected, the effects were considerably larger for people who fell into the doughnut hole. CONCLUSIONS: The ACA doughnut hole provisions likely contributed to a reduction in out-of-pocket spending for prescription drugs for part D beneficiaries, especially for people who fell into the doughnut hole.

The Role of Policy and Institutions on Health Spending.

This paper investigates the impact of policies and institutions on health expenditures for a large panel of Organisation for Economic Co-operation and Development countries for the period of 2000-2010. A set of 20 policy and institutional indicators developed by the Organisation for Economic Co-operation and Development are integrated into a theoretically motivated econometric framework, alongside control variables related to demographic (dependency ratio) and non-demographic (income, prices and technology) drivers of health expenditures per capita. Although a large share of cross-country differences in public health expenditures can be explained by demographic and economic factors (around 71%), cross-country variations in policies and institutions also have a significant influence, explaining most of the remaining difference in public health spending (23%). Copyright © 2016 John Wiley & Sons, Ltd.

Consumer-Centric Care: Latest Buzzword or New Reality?

With the industry in flux as federal healthcare reform legislation debates continue, leaders are preparing for what the post-Affordable Care Act world might look like. Predictions include patients assuming more responsibility for healthcare costs and therefore behaving like consumers, including choosing providers based on perceived value. What actions should chief nurse executives take to ensure the nursing enterprise responds to rising consumerism in healthcare?

The influence of fiscal rules on healthcare policy in the United States and the Netherlands.

Governments use fiscal rules to put a framework and limits on how budgetary challenges are addressed, but the rules themselves are still an understudied area among health policy scholars. For a long time, healthcare held a somewhat separate status because of the reliance on entitlements and dedicated revenue streams. However, the combined forces of advocates for integral decision-making, central budget control and the increasing costs might shift healthcare towards budgetary frameworks that currently apply to other spending categories. In this paper, we study fiscal rules that the US and the Netherlands have adopted since 2010 and their impact on healthcare policy. Our analysis shows that fiscal rules can have an impact on the rationing of healthcare. In the studied timeframe, the rules seem to have more impact on budget outcomes than on the budget process itself. In addition, the convergence of fiscal and program policy objectives seems to be better accomplished in a budgetary system that applies enforceable budget ceilings. Budgeting for health entitlements requires a comprehensive and tailor-made approach and the composition of traditional rules might not fully answer to the complexities of healthcare policy. This paper aims to contribute to that debate and the way we think about healthcare budgeting. Copyright © 2016 John Wiley & Sons, Ltd.